|Year : 2014 | Volume
| Issue : 1 | Page : 33-39
A five-year review of the pattern and outcome of cardiovascular diseases admissions at the Ekiti State University Teaching Hospital, Ado Ekiti, Nigeria
Ebenezer A Ajayi, Oladimeji A Ajayi, Olatayo A Adeoti, Taiwo H Raimi, Joseph O Fadare, Samuel A Dada, Michael A Akolawole
Department of Medicine, Ekiti State University Teaching Hospital, Ado Ekiti, Nigeria
|Date of Web Publication||7-Apr-2014|
Ebenezer A Ajayi
Department of Medicine, Ekiti State University Teaching Hospital, Ado Ekiti
Source of Support: None, Conflict of Interest: None
Background: In Nigeria, there is increasing urbanization and westernization of the population with resultant increase in non-communicable diseases. Though records of hospital admissions may not indicate the actual prevalence of such diseases in the community, it may provide clues about pattern and assist in disease-specific health promotion and education.
Objective: We, therefore, undertook this study to describe the pattern and outcome of cardiovascular diseases (CVD) admissions in a new referral hospital in Nigeria.
Methods: A five-year retrospective analysis of CVD admissions into the Medical Wards of Ekiti State University Teaching Hospital from May 2008 to April 2013 was done. SPSS IBM 20 software was used to analyze data.
Results: A total of 3,076 medical admissions were recorded with 1,009 (32.80%) being CVD. Mean age of CVD patients was 61.16±15.95 years. Patients aged >65 years accounted for 478 (47.8%) of the admissions. The 3 major CVD admissions were cerebrovascular diseases (47.7%), heart failure (27.6%), and hypertensive diseases (22.0%). Deaths due to CVD were 192 (19.0%) comprising mostly 136 (13.51%), 43 (4.26%), and 12 (1.19%) of deaths due to cerebrovascular disease, heart failure, and hypertensive diseases, respectively. Most deaths occurred within 3 days of admission with a decline in mortality with increasing length of hospital stay thereafter. Mean duration of hospitalization was 8.76±7.23 days.
Conclusion: Admissions from CVD to the medical wards in this hospital are high, so is mortality from them. We advocate for preventive strategies to reduce the burden of CVD and improved health care facilities to improve outcomes of their treatment.
Keywords: Admissions, cardiovascular diseases, hospitalization outcomes
|How to cite this article:|
Ajayi EA, Ajayi OA, Adeoti OA, Raimi TH, Fadare JO, Dada SA, Akolawole MA. A five-year review of the pattern and outcome of cardiovascular diseases admissions at the Ekiti State University Teaching Hospital, Ado Ekiti, Nigeria. Nig J Cardiol 2014;11:33-9
|How to cite this URL:|
Ajayi EA, Ajayi OA, Adeoti OA, Raimi TH, Fadare JO, Dada SA, Akolawole MA. A five-year review of the pattern and outcome of cardiovascular diseases admissions at the Ekiti State University Teaching Hospital, Ado Ekiti, Nigeria. Nig J Cardiol [serial online] 2014 [cited 2020 Aug 4];11:33-9. Available from: http://www.nigjcardiol.org/text.asp?2014/11/1/33/130098
| Introduction|| |
Hospitalization is both an adverse health event and a marker for serious health complications and is often predictive of disability.  Analysis of hospital morbidity and mortality can help to assess the standards of health care delivery, set health priorities as well as plan for health resources allocation. Such priorities setting and planning of health resources allocation should not only be focused on communicable diseases, but also on non-communicable diseases such as cardiovascular disorders. Hitherto, emphasis has been put on maternal-child health and infectious diseases issues in sub-Sahara Africa (SSA) despite the fact that cardiovascular diseases and their risk factors are increasing in the region. , In studies done in some referral hospitals in Australia, Hong Kong, South Africa, Ethiopia, and Nigeria, cardiovascular admissions accounted for 29.0%, 40.0%, 27.9%, 12.8%, and 19.8% of total hospital admissions, respectively. ,,,, The proportion of medical admissions due to cardiovascular diseases had increased over the years. In a report from the Northern part of Nigeria in 1979,  cardiovascular diseases accounted for 7.9% of medical admissions while a similar study in the southern part in 2008 reported that cardiovascular admissions accounted for 19.8% of medical admissions. In a review of several studies describing patterns of medical illnesses in patients admitted to hospitals in SSA between 1950 and 2010, Etyang et al. observed a five-fold increase from 3.9% in 1950-1959 to 19.9% in 2000-2010 in the proportion of admissions due to cardiovascular disorders with a concomitant reduction of 24% in infectious and parasitic diseases over the same period, despite the fact that HIV/AIDS epidemic was witnessed in the same region during the period. As cardiovascular admissions increased over the years, in-hospital mortality from them had also increased. In-hospital deaths from cardiovascular diseases in SSA increased from 9.7% in 1950-1959 to 19.4% in 2000-2010  with case fatality rate still very high at 21%.  It is now becoming obvious that non-communicable or chronic diseases are now the major causes of death and disability in low- and middle-income countries. ,
In Nigeria, like any country of developing world, there is increasing urbanization and westernization of the population with resultant changing of the morbidity pattern of diseases. ,, This changing pattern is mostly being pushed by increasing prevalence of cardiovascular risk factors such as hypertension including undiagnosed form of it as well as its poor control, diabetes mellitus, uncontrolled salt intake, cigarette smoking among others in the face of obvious appalling state of diagnostic and interventional facilities to manage these disorders.  Though review of records of referral hospital admissions may not indicate the actual prevalence of diseases in the community, it may, however, provide clues about the changing pattern of diseases affecting the community that such hospital serves in addition to assisting in disease-specific health promotion and education. In view of the above, we undertook this study to describe the pattern and outcome of cardiovascular admissions in a new referral hospital in Ekiti, Southwest Nigeria, where there is paucity of data on the subject matter.
| Materials and Methods|| |
A retrospective study was conducted from May 2008 to April 2013 on patients who were admitted to the medical wards of Ekiti State University Teaching Hospital (EKSUTH). EKSUTH, located in the State capital town, is a State Government-owned hospital that was established in April 2008 to serve as a tertiary and referral health center for the secondary and primary tiers of health care facilities in Ekiti State, Nigeria, a geopolitical region with a population of about 2.5 million people. The hospital also receives walk-in and referred patients from the neighboring states of Ondo, Kogi, Kwara, and Osun States within a catchment area of 150 km radius. There are 5 other tertiary hospitals within a 150 km radius, while there are 18 other general hospitals (secondary health care facilities) within the State. The hospital has 4 major (medical, surgery, gynecology/obstetrics, and pediatrics) wards and provides postgraduate training in internal medicine, gynecology/obstetrics, ophthalmology, and family medicine. The hospital has 300 beds and a total of more than 1000 employees, out which there were 8 specialists in the Department of Medicine who serve as the highest level of staff responsible for determining the final diagnoses given to patients. Male and female medical wards where the study was carried out have 49 beds. The main diagnostic modalities in the hospital are routine laboratory investigations, radiology, electrocardiogram, and histo-pathologic techniques. Easily assessable echocardiographic and neuroimaging services located outside the hospital complement the diagnostic facilities available within the hospital.
All patients who were admitted to the medical wards during the study period and whose records were captured in the admissions and discharges registers were included. The patient information in the registers included: Dates of admission and discharge or death or referral/transferal or left against medical advice (LAMA); name, address, age, sex; initial diagnosis (presenting or admission diagnosis), final diagnosis, and duration of hospital stay. Outcome variables like discharge with improvement, transfer to other wards, referral to other hospitals, death, and duration of hospital stay were noted. In this study, cardiovascular disease was defined as disease that affects the heart and blood vessels, and the main blocks of International Classification of Diseases 10 th version (ICD-10)  were used to sort out the final diagnoses in the register to group them into diseases. Ethics and research committee approval from the institution was obtained.
Means (Standard deviations) were used to describe the distributions of continuous variables. Percentages were used to describe categorical variables. Comparisons of categorical data were performed with the use of Pearson's Chi-square test. For continuous data, a Student t-test was used to compare means. Test for trend was carried out where necessary. All statistical analyses were performed with computer program IBM SPSS 20 (IBM Corporation, 2011). P < 0.05 was considered statistically significant.
| Results|| |
A total of 3,076 medical admissions were recorded over the 5 years period, out of which 1,009 (32.80%) were cardiovascular diseases admissions. Of the 1,009 patients admitted for CVD, 504 (49.95%) were males with a male to female ratio of approximately 1:1. The mean age was 61.16 ± 15.95 years (range 16-100 years). There was no statistical significance difference between the ages of male and female patients admitted (61.16 ± 15.87 vs. 61.45 ± 16.04 years, respectively; P = 0.778). Patients aged 16-44 years (young adults), 45-64 years (middle-aged adults), and >65 years (elderly) accounted for 148 (14.7%), 383 (38.0%) and 478 (47.8%), respectively, of the cardiovascular diseases admission. Specifically, 180 (17.8%) of the patients were older than 75 years of age.
Pattern of diseases
The 3 major cardiovascular diseases that were admitted during the review period were cerebrovascular diseases (47.7%), heart failure (27.6%), and hypertensive diseases (22.0%). The proportion of admissions due to ischemic heart diseases (0.5%) and rheumatic heart diseases (0.9%) was low compared with the diseases listed above. There was a stepwise increase in the proportion of cerebrovascular diseases and heart failure admissions with increasing age [Table 1]. In contrast, the young and middle-aged patients constituted the bulk of admissions due to hypertensive diseases (70.7%). Of the 9 patients admitted for rheumatic heart diseases, 8 (88.9%) of them were young people (age group 16-44 years). As shown in [Table 2], the proportions of cardiovascular diseases admissions were comparable in both sexes. Even though there was no major change in the trend of admissions due to cerebrovascular diseases and heart failure over the review period, a decline in hypertensive diseases admissions was noticed [Table 3].
The mortality due to cardiovascular diseases during this review period was 192 (19.0%) comprising 136/1009 (13.51%), 43/1009 (4.26%), and 12/1009 (1.19%) of deaths due to cerebrovascular disease, heart failure, and hypertensive diseases, respectively. Majority of the patients (70.9%) were discharged home with improvement in their clinical conditions. The rate at which patients left hospital against medical advice was 6.6% [Table 4]. As shown in [Figure 1], the outcome of admission measures appear to have weakly favored female patients compared with male patients (X 2 = 7.938, Confidence Interval, CI = 0.40-0.50; P = 0.047). Disease- specific mortality rate is shown in [Table 4]. There was a downward trend in mortality rate from cerebrovascular diseases to heart failure and hypertensive diseases (Chi-square = 54.63, P < 0.005). Of the 192 (19.0%) patients who died while on admission, 7.8%, 33.9%, and 58.3% of the deaths occurred in 16-44, 45-64, and >65 years age group, respectively. In general, [Figure 2] demonstrated the mortality trends across different age groups in the 3 diseases that constituted majority of admissions.
|Figure 2: Distribution of deaths of the three most common diagnoses over the age groups|
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Length of hospitalization
Duration of hospital stay ranged from 1 to 57 days (median, 7 days), with a mean duration of 8.76 ± 7.23 days. Female patients stayed longer than male patients, though not statistically significant (9.19 ± 7.69 vs. 8.76 ± 7.23 days, P = 0.102). As shown in [Figure 3], duration of hospital stay increased from the young age group of 16-44 years to middle age group of 45-64 years and elderly, though this was also not statistically significant (7.47 ± 5.46 vs. 8.67 ± 7.00 vs. 9.20 ± 7.80, P = 0.067). The mean duration of hospital stay in respect of the disease conditions is shown in [Table 5]. As shown in [Table 6], most of the patients (71.06%) stayed on admission for less or equal to 10 days while 26.6% stayed for ≤3 days. Only 1.39% stayed for >30 days on admission, out of which 85.7% were patients admitted for cerebrovascular diseases that aged 65 years and above. Most of the deaths occurred within 3 days of admission, and there was a decline in mortality with increasing length of hospital stay thereafter.
|Table 6: Trends of duration of hospitalization versus outcomes, age group, and sex|
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| Discussion|| |
In this study, 32.8% of admissions to our medical wards were as a result of cardiovascular diseases. This finding is higher than what was reported in studies done in the South-South part of Nigeria between 1996 and 2001  and Southwest Ethiopia in 2008  but comparable to the findings of similar studies done in referral hospitals in Australia, Hong Kong, and South Africa. ,, The wide difference between our study and other studies with similar results from the Ethiopian study with cardiovascular diseases admissions prevalence of 12.8% may be explained by the fact that young adults between 21-30 years of age (mean age of 36 years) constituted the majority of their admissions in contrast to mean age of 61 years in our study. The effect of age distribution of population in respect of pattern of diseases is well known. This is known not only between different disease categories, but also within a specific disease category. For instance, rheumatic heart disease is seen predominantly in the young while atherosclerotic diseases are the common cardiovascular problems of the older age groups.  Findings in this study are in agreement with this observation. Even though the proportion of admissions due to rheumatic heart disease is low in this study compared with some previous studies from other low- and middle-income countries, , majority of it was still seen in the young adults. This is not surprising despite the fact that Africa is burdened by rheumatic heart disease; the disease is predominantly found in school children , whose records of admissions were substantially excluded from this study since they are usually admitted in the children wards.
We observed in this study that hypertensive diseases were seen more on admission in the young and middle-aged adults while the resultant complications in the continuum, cerebrovascular diseases and heart failure, were seen more in the older age group. Among the several risk factors and causes of cerebrovascular disease and heart failure, hypertension has been reported to play a major contributory role; ,, partly related to its high prevalence and poor treatment and control. The pattern of admission due to hypertensive heart diseases trended downward over the review period with no significant change in the trend of admission due to cerebrovascular diseases and heart failure. It is likely that the improved organization and care occasioned by the presence of specialists in the outpatient management of patients with hypertension in this hospital was responsible for the observed decline.
Cerebrovascular disease prevalence differs between African countries and ethnic groups, possibly due to their differing stages in the epidemiologic transition, lifestyle factors, and health-care access.  It has been reported that stroke burden in Africa is high with individuals in younger ages being more affected compared with high-income countries. ,, However, what has been found in this study suggested otherwise. That the burden of cerebrovascular disease is heavy is in agreement with our findings, but older individuals were more affected than people with younger ages. In a hospital-based study in The Gambia, the mean ± SD age at stroke was 58 ± 16 years while it ranged between 61 ± 3.7 to 75 ± 5.0 years, depending on the pathological type of cerebrovascular disease (higher in intracerebral hemorrhage type) in another study from South West Nigeria.  A study from South-South Nigeria put the mean age at presentation at 62.62 ± 14.2 years.  The mean age for cerebrovascular disease presentation in our study was 64.13 ± 14.60 years. In one community-based study, age-standardized incidence of stroke in rural Tanzania was similar to that seen in high-income countries, and in the urban location was higher than among African Americans.  The low proportion of admissions from ischemic heart disease and mortality from it in our study reinforces previous suggestions that prevalence of ischemic heart disease is low, though it has been argued that there is an upward trend in its prevalence. 
Analysis of hospital mortality can help to assess the standards of health-care delivery. Mortality rate due to cardiovascular admissions in this study was high (19%) but similar to what had been reported previously. , Abengowe et al. reported an in-hospital mortality rate of 20% in 1979 in a study done in Northern Nigeria. The proportion of deaths caused by disorders of the cardiovascular system rose from 9.7% in 1950-59 to 19.4% in 2000-2010.  Cerebrovascular disease (13.51%) was the commonest cause of cardiovascular deaths followed distantly by heart failure (4.26%) in this study. These findings are similar to previous reports. , Most of the deaths in this study occurred within the first 3 days of admission, probably because of severity of illness as a result of delay in seeking care, which had been established in some other studies.  Many of our patients usually present late to the hospital probably because of ignorance, poverty, and apathy to the efficiency of orthodox medical care. It has been suggested that there is a relationship between duration of hospital stay and mortality with patients who died having a shorter hospital stay than those who survived.  A reduction in delay in seeking care have been suggested to result in improved outcomes such as lower mortality rates, improved quality of life, and reduced resource utilization and healthcare treatment costs.  There is a gradual decline of deaths from infectious diseases in the developing countries with a concomitant increase in the proportion of deaths from non-communicable diseases  and mortality from cardiovascular diseases relating to atherosclerosis increases when age increases.  Mortality rate, including certain disease-specific mortality rate such as cerebrovascular diseases and heart failure, increased with increasing age in this study. It is, therefore, important to stress the need to put in place strategies geared towards reducing cardiovascular disease risk factors in the community as well as their proper management. Health education and promotion, health-care facilities improvement, and training and re-training of health care providers among other things should be reinforced.
In conclusion, admissions from cardiovascular diseases to the medical wards in this hospital are high, so is mortality from them. Cerebrovascular disease is the commonest reason for these admissions with heart failure in a distant second position with both diseases responsible for most of the deaths. Most of the deaths occurred within the first 3 days on admission and among the older age group compared with the young adults. We advocate for preventive strategies to reduce the burden of cardiovascular diseases and improved health care facilities to improve outcomes of their treatment.
This study is not without its limitations. The retrospective, records-based nature of the study made it difficult to validate data for accuracy or completeness of records. Though the usefulness of hospital-based data for public health priority setting cannot be overemphasized, caution should be exercised in extrapolating the results of such data to the general population.
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[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]